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Asymptomatic morgagni hernia in a neonate
I NSIGHTS
Asymptomatic Morgagni hernia in a neonate A male infant was born at term by vaginal delivery to a 17-year-old primigravida. Antenatal ultrasonography at 40 weeks was suspicious of intraabdominal calcifications. The infant was born in good condition. No dysmorphic feature was noted on physical examination. Day one follow-up chest and abdominal radiograph of this asymptomatic infant revealed a well-circumscribed hemispheric anteromedial chest mass, contiguous with the right hemidiaphragm, with mild secondary mediastinal shift (Fig 1). An abdominal ultrasonography was performed on day 2 and revealed a partial herniation of the liver, measuring approximately 3 2.2 2 cm through the foramen of Morgagni into the right hemithorax (Fig 2). The herniated segment was adjacent to the right ventricle and minimally displacing the cardiac structures. The infant was discharged home on day 2 after surgical consultation and arrangement for an outpatient surgical visit had been made. Morgagni hernia occurs when there is a congenital defect in the attachment of the anteromedial aspect of the diaphragm to the ribs and sternum. It is the least common type of diaphragmatic hernia1 and can occur in adults with minimal to no symptoms.2 It may appear in the neonatal period with respiratory distress, similar to Bochdalek’s hernia. The size and the contents of the herniated segment may determine the time and severity of clinical presentation. Morgagni hernia has been associated with other congenital abnormalities, including congenital heart disJ Pediatr 2002;140:466. Copyright © 2002, Mosby, Inc. All rights reserved. 0022-3476/2002/$35.00 + 0 9/45/122084 doi:10.1067/mpd.2002.122084
466
Fig 1. Focal right anteromedial hemispherical mass continuous with the right hemidiaphragm with mild contralateral mediastinal shift. ease, gastrointestinal tract abnormalities, and trisomy 21.3 Diagnosis can be made by viewing a chest radiograph, which may reveal an anteromedial mass. There may be an association with parietalproperitoneal-peritoneum line, demonstrating a contour known as the sign of the cane.4 Differential diagnoses include pericardial fat, sequestration of the lung, or a space-occupying lesion. In the neonatal period, the diagnosis is usually confirmed by ultrasonography, which permits accurate anatomic localization of the diaphragmatic defect, quantification of the size of the diaphragmatic defect, identification of the herniated contents and accompanying vascular pedicles, and the degree of cardiac displacement.1,4 Computed tomography may on occasion be required to further define the herniated contents; contrast studies are rarely indicated. Surgical repair usually results in complete correction, although severe pulmonary hypoplasia has been occasionally noted. Prakeshkumar Shah, MD, MRCP, MRCPCH Phyllis Glanc, MD, FRCPC Eugene Ng, MD, FRCPC Department of Newborn and Developmental Pediatrics
Fig 2. Longitudinal right parasagittal ultrasonographic image demonstrates diaphragmatic discontinuity (arrows), indicating a diaphragm gap of ~2.9 cm, and cephalad herniation of the liver.
Department of Medical Imaging Sunnybrook and Women’s College Health Sciences Center University of Toronto Ontario, Canada
REFERENCES 1. Berman L, Stringer D, Ein SH, Shandling B. The late-presenting pediatric Morgagni hernia: a benign condition. J Pediatr Surg 1989;24:970-2. 2. Thomas GG, Clitherow NR. Herniation through the foramen of Morgagni in children. Br J Surg 1977;64: 215-7. 3. Pokorny W J, McGill CW, Harberg FJ. Morgagni hernias during infancy: presentation and associated anomalies. J Pediatr Surg 1984;19: 394-7. 4. Lanuza A. The sign of the cane: a new radiological sign for the diagnosis of small morgagni hernias. Radiology 1971;101:293-6.
Asymptomatic Morgagni hernia in a neonate A male infant was born at term by vaginal delivery to a 17-year-old primigravida. Antenatal ultrasonography at 40 weeks was suspicious of intraabdominal calcifications. The infant was born in good condition. No dysmorphic feature was noted on physical examination. Day one follow-up chest and abdominal radiograph of this asymptomatic infant revealed a well-circumscribed hemispheric anteromedial chest mass, contiguous with the right hemidiaphragm, with mild secondary mediastinal shift (Fig 1). An abdominal ultrasonography was performed on day 2 and revealed a partial herniation of the liver, measuring approximately 3 2.2 2 cm through the foramen of Morgagni into the right hemithorax (Fig 2). The herniated segment was adjacent to the right ventricle and minimally displacing the cardiac structures. The infant was discharged home on day 2 after surgical consultation and arrangement for an outpatient surgical visit had been made. Morgagni hernia occurs when there is a congenital defect in the attachment of the anteromedial aspect of the diaphragm to the ribs and sternum. It is the least common type of diaphragmatic hernia1 and can occur in adults with minimal to no symptoms.2 It may appear in the neonatal period with respiratory distress, similar to Bochdalek’s hernia. The size and the contents of the herniated segment may determine the time and severity of clinical presentation. Morgagni hernia has been associated with other congenital abnormalities, including congenital heart disJ Pediatr 2002;140:466. Copyright © 2002, Mosby, Inc. All rights reserved. 0022-3476/2002/$35.00 + 0 9/45/122084 doi:10.1067/mpd.2002.122084
466
Fig 1. Focal right anteromedial hemispherical mass continuous with the right hemidiaphragm with mild contralateral mediastinal shift. ease, gastrointestinal tract abnormalities, and trisomy 21.3 Diagnosis can be made by viewing a chest radiograph, which may reveal an anteromedial mass. There may be an association with parietalproperitoneal-peritoneum line, demonstrating a contour known as the sign of the cane.4 Differential diagnoses include pericardial fat, sequestration of the lung, or a space-occupying lesion. In the neonatal period, the diagnosis is usually confirmed by ultrasonography, which permits accurate anatomic localization of the diaphragmatic defect, quantification of the size of the diaphragmatic defect, identification of the herniated contents and accompanying vascular pedicles, and the degree of cardiac displacement.1,4 Computed tomography may on occasion be required to further define the herniated contents; contrast studies are rarely indicated. Surgical repair usually results in complete correction, although severe pulmonary hypoplasia has been occasionally noted. Prakeshkumar Shah, MD, MRCP, MRCPCH Phyllis Glanc, MD, FRCPC Eugene Ng, MD, FRCPC Department of Newborn and Developmental Pediatrics
Fig 2. Longitudinal right parasagittal ultrasonographic image demonstrates diaphragmatic discontinuity (arrows), indicating a diaphragm gap of ~2.9 cm, and cephalad herniation of the liver.
Department of Medical Imaging Sunnybrook and Women’s College Health Sciences Center University of Toronto Ontario, Canada
REFERENCES 1. Berman L, Stringer D, Ein SH, Shandling B. The late-presenting pediatric Morgagni hernia: a benign condition. J Pediatr Surg 1989;24:970-2. 2. Thomas GG, Clitherow NR. Herniation through the foramen of Morgagni in children. Br J Surg 1977;64: 215-7. 3. Pokorny W J, McGill CW, Harberg FJ. Morgagni hernias during infancy: presentation and associated anomalies. J Pediatr Surg 1984;19: 394-7. 4. Lanuza A. The sign of the cane: a new radiological sign for the diagnosis of small morgagni hernias. Radiology 1971;101:293-6.